Letter from the Directors
September 2006
Colleagues
This letter highlights selected, recent quality
and patient safety activities at Loyola. These successes are the result
of the efforts of numerous physicians, nurses, administrators, and staff
throughout LUHS. I am sure you will agree with our assessment that
together we continue to make substantial improvements in the quality and
safety of care.
Loyola Care - Creating a
Consistent, State-of-the- Art, Evidence-Based Approach to Clinical Care
Management of
diabetes in hospitalized patients:
Under the leadership of Dr. Mary Ann Emanuele, implementation of
guidelines and order sets have resulted in a 12% decrease in median blood
glucose from 157 to 137 mg/dL among hospitalized diabetics. Even more
impressive, the percentage of patients with normal blood sugar the morning
following cardiac surgery has increased three-fold from 13% to 45%!
Surgical infection prevention (SIP):
This
project, led by Dr. Scott Jellish,
continues to make
progress. Antibiotics are being administered within 1hour of surgical
incision to 94% of patients and a recent change to include this as part of
the preoperative timeout should produce further gains. Appropriate
antibiotics are being used more than 80% of the time and are being
discontinued within 24hours in more than 70% of cases.
Reducing central venous line associated sepsis.
This project, led by Dr. Stuart Johnson, Infection Control Staff, and ICU
leadership, has achieved major success. Line-associated bloodstream
infections in adult ICUs now average 2.1 infections/1,000 line days, a
rate 58% below that in 2004 when the project began!
Reducing
post-operative venous thromboembolism: Under the leadership of Dr.
John Santaniello and Himani Lawson-Singh, R.N., a new risk assessment tool
and standard orders have been implemented in the Department of Surgery to
ensure that high-risk patients without contraindication receive
pharmacologic prophylaxis. Planning is underway to implement these tools
over the next few months in Orthopaedics and Neurosurgery.
JCAHO Core Measures:
We continue to report results of nationally standardized quality
indicators for acute myocardial infarction, congestive heart failure and
pneumonia (http://www.medicare.gov/Hospital/Home.asp).
LUHS performance on most measures is excellent. We have made major
progress in smoking cessation counseling and providing pneumococcal and
influenza vaccines to high-risk patients. Multidisciplinary teams continue
to identify and address areas where our performance needs improvement.
Pain management
order sets: The Pain Management Committee has worked hard to improve
standardized pain management order sets for hospitalized adults. We are
currently working with clinical leadership to ensure that all departmental
EPIC order sets employ a consistent, evidence-based approach to pain
management.
Patient Safety
Patient safety is a major priority for LUHS. The LUHS-wide Patient
Safety Plan focuses on four major goals: (1) creating a culture of
safety; (2) adverse event and near misses reporting and analysis; (3)
medication safety; (4) focused projects that address key system-wise
processes, i.e., National Patient Safety Goals. Numerous activities are
underway to address each of these areas. Selected examples include:
In order to create a
more integrated program around patient safety, the Department of Risk
Management has been renamed the Department of Patient Safety and Risk
Management. Monica Berry R.N., J.D. has joined Loyola as the new Director
of this department. Among other projects, Monica is currently leading
efforts to identify and implement an electronic adverse event reporting
system during the coming year. This will make it much easier for staff and
physicians to report patient safety events and will make it possible to
provide feedback to those who report.
Learning Map: This group exercise, directed by
Kathy Orms, Director of Organizational Development, with the assistance of
45 leaders throughout LUHS, highlighted the need and opportunity to
improve service and patient safety. Every LUHS employee and a large number
of faculty and residents participated in this important conversation.
National Patient Safety Goals: Excellent
progress has been made on many of the thirteen goals. There is a need for
ongoing effort to eliminate the use of unapproved abbreviations and to
ensure consistent use of the universal protocol (pre-procedure
verification, site marking, and time-out) to prevent wrong patient, wrong
site procedures/surgery. A new EPIC-based process for medication
reconciliation (creating an accurate list of meds that is available to all
caregivers at admission, discharge and transfer) is currently being
implemented. Finally, projects are underway to standardize handoffs
(sign-outs) by nurses and residents and to ensure labeling of all
medications on sterile fields for all operative and bedside procedures.
Improving Regional and
National Visibility of LUHS Quality Improvement Efforts
We are working to improve professional and public knowledge of our quality
improvement efforts in a number of ways. Data about our performance is
regularly updated on the LUHS and CCE websites (see
www.luhs.org/quality and
www.luhs.org/cce).
Leapfrog Survey: LUHS was one of two academic
medical centers in Chicago, and among a minority of hospitals throughout
the metropolitan area, that completed the entire survey in 2005. We
recently updated the survey and our results demonstrate substantial
improvement.
LUHS remains an active participant in the University
HealthSystem Consortium (UHC). This past year, LUHS was ranked 16th
out of the 92 academic medical center members of UHC on broad measures of
quality and patient safety.
LUHS has enrolled in the Institute for Healthcare
Improvement (IHI) 100,000 Lives Campaign (www.ihi.org).
Over 2,800 hospitals have enrolled in this national effort to reduce
preventable hospital deaths by a number of means including decreasing
nosocomial infections, improving heart attack care, and reducing adverse
medication events. Inpatient mortality at LUHS is now 16% below levels
predicted by UHC.
Loyola hosted the annual meeting of the Chicago
Patient Safety Forum on March 3, 2006. More than 250 registrants
participated in lectures, poster session and workshops. LUHS physicians
and staff presented a workshop and two posters. Invited speakers included
several nationally prominent patient safety and policy experts as well as
Dr. Eric Whittaker, Director of IDPH.
Patient Safety Week and the Annual LUHS Quality
and Safety Fair
Patient safety week was celebrated March 6-10, 2006. More than 500 staff
visited engaging educational displays in the Fitness Center lobby and
messages were delivered across LUHS in various formats.
The 9th annual Quality and Safety Fair,
held in April, was a major success. Over twenty improvement projects were
presented as storyboards and displayed in SSOM. Dr. Mark Keroack, Vice
President and Julie Cerese, Senior Director of the Clinical Practice
Advancement Center at the University HealthSystem Consortium, made
presentations on patient safety to the LUHS Board, LUHS staff, and the
LUPF general membership.
We are here to assist you in
your efforts to improve the quality, safety, and value of the care
provided by LUHS. Please call us at 6-3290 and visit our web page on the
LUHS website under Departments (www.luhs.org/cce).
We look forward to your ideas, guidance, and partnership.
William
M. Barron, M.D., M.M.M., F.A.C.P.
Vice President, Quality and Patient Safety
Professor of Medicine |
Anne L. Porter, R.N.,
Ph.D.
Associate Vice President, Quality and Patient Safety |
